Pernio Clinical Presentation

Updated: Mar 07, 2017
  • Author: Michele S Maroon, MD; Chief Editor: William D James, MD  more...
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Most patients with pernio present with a history of recurrent painful and/or pruritic, erythematous, violaceous papules or nodules on the fingers and/or toes. Most cases of pernio resolve within 2-3 weeks. Elicit a history of cold exposure or repeated episodes of cold exposure.


Physical Examination

Pertinent findings in pernio are limited to the skin. Cutaneous pernio lesions present 12-24 hours after cold exposure as red or violaceous macules, papules, nodules, or plaques, which may form vesicles or ulcerate. Pernio lesions occur on acral areas, are associated with burning or pruritus, and last 1-3 weeks. Note the images below.

Close-up of erythematous macules and plaques on di Close-up of erythematous macules and plaques on distal plantar toes.
Close-up of great toe bulla. Close-up of great toe bulla.


The direct cause of pernio is cold exposure; specifically, exposure to both mild nonfreezing cold and humidity seems to be required. [5, 6] Chronic pernio may be secondary to various systemic diseases as follows:

Variants include the following:

  • Kibes (equestrian cold panniculitis): Erythrocyanotic plaques occur on the upper lateral thighs of women who ride horses. Histology is characterized by an intense perivascular infiltrate extending into subcutaneous fat.
  • Chilblain lupus erythematosus [11, 12] : Violaceous "pernio" plaques appear prominent over dorsal interphalangeal joints, often with positive antinuclear antibody (ANA) or rheumatoid factor (RF). Histologic and immunofluorescent evidence of lupus is present in the skin lesions. Half of the patients have associated facial discoid lupus lesions, and 15% develop systemic lupus.
  • Drug-induced pernio: Sulindac-induced cases have been reported. [13]


Pernio lesions that blister may become secondarily infected.